31 January 2006

I think we have just witnessed the effective end of the Bush presidency. Yes, wishful thinking, I can admit, but wow. The most positive comment I have heard was "modest." Where is the bold Commander Codpiece of a year ago, striding forth and spending his hard-earned political capital on such visionary plans as reforming social security and the tax code? Where is the budget-impaired adolescent of three years ago who proudly declared "Mars or Bust"? Ah, what a sad thing it is when a year of incompetence and corruption reduce him to a 39% approval-rating shell of a man whose bravest proposal was to ban human-animal hybrids (really).

It cracked me up when he lamented that "congress did not act" on his Social Security proposal, giving the Democrats their best (only) applause line of the night.

What happened to Health Care? The run-up said that this would be the big focus of the SOTU, with big big proposals, but there was one paragraph dedicated to health care, and it basically was a plea for malpractice reform (dead) and minimal changes to Health Savings Accounts, which nobody uses anyways. Bit of a bait and switch, there, but not too funny to the 47 million uninsured Americans.

"America is addicted to oil, which is often imported from unstable parts of the world." Are you fricking kidding me? This from the man who spent the last five years as the "Oil president" and presided over the biggest profits ever for the energy industry? Yes, and the oil producing countries are unstable, aren't they -- they keep getting invaded and hosting inconvenient insurgencies and having their presidents overthrown by US-backed coups. How irritiating.

Say, whatever happened to the hydrogen cars he promised us a couple of years ago?

And the man who added $17 Trillion to the nation's liabilities manages to crow about $14 Billion in deficit reductions. With a straight face.

An odd silence on the lobbying scandal on the hill, and minimal red meat thrown to the base -- passing mentions only of gay marriage, stem cells, and abortion.

I think this speech will be forgotten by the end of the week, and absent an agenda this year, I can't see that the era of Bush will have any other opportunity to introduce any expansive plans or radical changes (thank goodness), since this year will be consumed by electoral politics, and by 2007, the focus will be on the next president. Sure, Bush will have another three years to inflict damage on the country with his control of the executive branch and judiciary -- it will take us a long time to undo the damage, to be sure. But I got a real feeling of a turning of the tide tonight, that his window of opportunity is closing and that the long dark night is finally coming to an end.

Been back from Whistler a few days; had a lovely time (happiness is the sound of fresh powder hissing over the front of your skis), but now we are dealing with a big kid with Scarlet Fever and a smaller one who is teething, while I work nights, so blogging hasn't been high on my agenda for a few days.

In the interest of rebuilding momentum, I offer this bit regarding whether our Attorney General perjured himself when he was being confirmed.

On direct questioning, Gonzales dismissed the possibility of warrentless wiretaps as a "hypothetical situation," when he was already aware of the existence of such a program, further adding that it was "not the policy or the agenda of this president to authorize actions that would be in contravention of our criminal statutes." I suppose that could be interpreted to mean that if the president decided to overrule a law, he would only do it occassionally.

Remember when we impeached the president for hair-splitting lies in a private sexual harassment suit? And now the Attorney General lies about matters of national security and civil liberties to the US Senate, and it gets buried on page A7.

23 January 2006

Thanks to my wonderful wife, I had the pleasure of attending today's NFC Championship game, where the Seattle Seahawks trounced the hapless Carolina Panthers.

Man, what an intense experience. We sat at about the 10-yard line about 20 rows back. Amazing seats with an amazing view. And what a game -- the Panthers' offensive output in the first half was like three first downs and 40 yards of total offense. Yikes. I am not generally a good football fan because I get too emotionally involved in the game; I just can't be a casual onlooker. This game was even more supercharged because, of course, the Super Bowl was riding on it. What fun. I am still riding the euphoric high.

The Hawks are looking pretty good for Detroit in Superbowl XL, but the Steelers have looked awesome as they've systematically dismantled the three (other) best teams in the NFC. Should be a good game.

No blogging for a few days, likely, since I am off to Whistler for a few days of skiing.

20 January 2006

I think I have found a new daily read blog. As many of you know, I take my comics seriously. A bit too seriously. In medical school, we used to all get together after anatomy class and have the ritual "Reading of Fred Bassett," the least-funny comic strip ever. It was a solemn event, followed by an explication of the text and an meta-analysis of why it might have been thought to be funny, or any deeper philosophic themes in the subtext.

Well, this guy has taken the reading of Fred Bassett to the next level, and I love him for it. Here is an example of his work:

It has come to my attention that some of my readers do not find Get Fuzzy amusing. These people are, for lack of a more subtle word, wrong. Let us count the things that made me laugh about today’s installment:

The phrase “he would reject it as being unrealistically squalid.”

Rob’s spindly legs.

Bucky’s palms-up outspread paws.

Bucky’s pot belly.

Bucky’s sly look. Imagine if Sally Forth used the phrase “shoebox full of dead rats” when she deployed her sly look. That feature would be improved thereby.

The phrase “a shoebox full dead rats.”

If you are not convinced, there is no hope for you. Now if you’ll excuse me, my cat is demanding to be let in from the back porch. Hopefully she doesn’t have another rat to add to the shoebox.

He also, god bless him, reads Family Circus for us, so we don't have to.

17 January 2006

I am in Vegas, for a conference, and there's not too much to do here if you don't like to gamble. And I don't like to gamble. For one, I can do math, and I hate to give more money to the casinos when they clearly already have too much of it. And two, I have not had much luck the few times I have gambled. But most of all, I just don't find it to be a lot of fun, even when with friends and family and drinking, even less when I am bitter, sober, and alone.

So I decided to treat myself to nice food while I am here.

I went to The Picasso at the Bellagio, a really nice French-Mediterranean place with $75 Million in original Picasso artworks decorating the place. Yeah, that kind of place. The food was as exquisite as you might expect, and since I was flying solo, I spent a bit of time chatting with the waiter and quizzing him on the unfamiliar food items.

"What's this?""This is foie gras mousse on brioche.""And the bit on top?" I asked, indicating a clear jello-like blob on top."Muscat gelato with proscuitto.""Oh. And what is muscat gelato?""It's a sweet dessert wine made into a jelly.""Of course."----next course----"So what is this, then?""Crusted Sea Bass with a saffron sauce.""And these white things?" I asked, pointing to some round dollops of uncertain origin."Cauliflower mouslin.""Aha."----next course----"Fallow deer with a port wine reduction.""Sounds good. And what is this?" I asked, indicating a small oblong orange thing."That, sir, is a carrot," he replies without a trace of condescension."I see."

16 January 2006

Al Gore, introduced by Republican Bob Barr, calls for the appointment of a special prosecutor to investigate Bush's illegal wiretaps.

One of the other ways the Administration has tried to control the flow of information is by consistently resorting to the language and politics of fear in order to short-circuit the debate and drive its agenda forward without regard to the evidence or the public interest. As President Eisenhower said, "Any who act as if freedom's defenses are to be found in suppression and suspicion and fear confess a doctrine that is alien to America."

Fear drives out reason. Fear suppresses the politics of discourse and opens the door to the politics of destruction. Justice Brandeis once wrote: "Men feared witches and burnt women."

The founders of our country faced dire threats. If they failed in their endeavors, they would have been hung as traitors. The very existence of our country was at risk.

Yet, in the teeth of those dangers, they insisted on establishing the Bill of Rights.

Is our Congress today in more danger than were their predecessors when the British army was marching on the Capitol? Is the world more dangerous than when we faced an ideological enemy with tens of thousands of missiles poised to be launched against us and annihilate our country at a moment's notice? Is America in more danger now than when we faced worldwide fascism on the march-when our fathers fought and won two World Wars simultaneously?

It is simply an insult to those who came before us and sacrificed so much on our behalf to imply that we have more to be fearful of than they. Yet they faithfully protected our freedoms and now it is up to us to do the same.

We have a duty as Americans to defend our citizens' right not only to life but also to liberty and the pursuit of happiness. It is therefore vital in our current circumstances that immediate steps be taken to safeguard our Constitution against the present danger posed by the intrusive overreaching on the part of the Executive Branch and the President's apparent belief that he need not live under the rule of law.

15 January 2006

I'm in Vegas at this heinous reimbursement conference, and I wanted to have a decent dinner tonight. The restuarants where I am staying (Harrah's) are pretty scuzzy, but the Venetian is across the street. So I checked out their menus and prices online, picked one that seemed nice but affordable, and went on over.

I was in a mood to treat myself a little (because I'm lonely and would rather be at home) so I decided to order a bottle of wine. They brought me a book three inches thick, and I opened the first page, and the Sommelier pointed out the fields for the region the wine was from, the style, then name, and the date. I noted these four and five-digit numbers, which I assumed were SKU numbers, but before I could embarass myself, the Sommelier indicated that they were in fact the prices.

Oops.

It took a little doing, but I found a reasonable bottle of wine for only $50/bottle. (At this point, leaving was no longer an option, since I had ordered an appetizer. Also, I didn't want them to think I was a wimp.) The Sommelier described it as "full-bodied," in contrast to the wines he condescendingly described as "soft." I ordered, and after opening the wine bottle with a flourish he gave me a taste and waited expectantly for my verdict. It was really harsh, very bitter and unpleasant, I thought, and made a nasty face. He was appalled that I might have gotten a bottle gone bad, and ran off to get a glass to test it himself. He poured in a dribble, sniffed deeply, and pronounced with a definite tone, "No. The wine is sound. You haven't had anything to eat yet, so the tannins are very hard on your palate. You will like it once your meal arrives. But," he politely added, "if you would prefer something different . . ."

Thoroughly cowed, I meekly asserted that it was just fine and as soon as I could get that gag reflex suppressed there would be no trouble . . .

And actually, he was right. It wound up being a really nice wine and a really nice dinner.

11 January 2006

I used to ask why people bet on things like baseball and football, sports that were in and of themselves good and true and beautiful and all that, and the inevitable response was that it increased your interest level and made it a little more fun.

I didn't quite get it, until now.

This is Apple Computer's stock price for the past five days. The big bounce (for those of you living under a rock) came after they introduced the new product line. Why this caused such a dramatic reaction is beyond me, since it was the worst-kept secret since "Who killed JFK?"* that they would be introducing Intel-based PowerBooks MacPro laptops. I guess the new iMacs came a little sooner than expected, but enough to add 10% to the already-overvalued market cap of Apple?

Okay.

But anyway. Now I get it. I used to follow Apple like I follow the Cubs, with a passion bordering on obsession and a vague sense of inevitable doom. But a year and a half or so ago, on a whim, I bought $5,000 of AAPL stock. That stock is now worth upwards of $20,000 (which accounts for 2/3 of my total portfolio's appreciation). I care on a totally different level now. I'm still a fan, but a fan with money on the table. So like the football fan who cheers when their team kicks a meaningless field goal to cover the spread, I now cheer when their quarterly returns not only show a profit, but beat the analysis' expectations by $0.03 per share.

And even better, I have had the good fortune to join the game right when the iPod lit the booster that propelled AAPL into orbit. So I am enjoying the ride, expect that I will someday lose all my gains, and plan to ride AAPL all the way back down to the ground. Lest you all think I am an idiot, I mostly invest with my head and not my heart -- I bought AAPL, Pixar, and Boeing because I like (and know a lot about) the companies. I bought Starbucks with a similar attitude, but would ditch it in an instant if it tanked. The other holdings I have are pretty mundane -- 3M, Exxon, Genentech, etc., and I have defined stop-loss sell points on them.

But they're like betting on the New England Patriots. I expect them to win and am pleased when they do, but take no real pleasure in it. So I guess the conclusion I can make is that betting on "your team" makes it a lot more fun when they win, and (for me, anyway) betting on other teams has minimal allure.

09 January 2006

For some time, long ago, I worked as a waiter. It was a fun and challenging job and I was pleased that I got pretty good at it. At the time, I was vaguely embarrassed that I took such pride in being good at a generally menial job. But there was a real learning curve, and not every person who worked there seemed to "get it." The difficult thing to learn was not the menu or anything like that, but the mental organization to keep a running, prioritized "to-do" list in your head. e.g., "Table 31 needs salt, 32 needs to be greeted, 33's order should be up any minute and I have to go to the kitchen and look for it, and 34 is going to want their check soon and I need to go ask if they want dessert." It sounds pretty simple, but when you consider that items are constantly being added to or dropped from the list, and they carry different priorities, and some are quick and easy while some tasks are more involved, and some need to be done immediately, while others are less urgent, you can see that it's a pretty dynamic process requiring a sophisticated decision-making algorithm.

I forgot about this for a while, until I started working in the ER. Then I went through the same learning curve, as I again learned to manage my live to-do lists. It did not take long for me to recognize the similarity between my new and former jobs. I was now, I joked, a "medical waiter."

What I am interested in is the heuristic model with which I (and other successful waiters/docs) keep our time effectively managed. To formalize the model a little: view each patient as a project, for which my goal is to move them to discharge or admission in order to free up the bed for the next patient languishing in the waiting room. The enviroment is such that time is the most valuable commodity. I am always managing multiple projects in parallel, with no commonality between projects. For each patient I can pretty quickly define the things I will need to do to accomplish this disposition: initial greeting; data collection; therapy; communication and disposition.

In order to do this, I create and continually update a multivariable ranking “to-do” list. The most critical variables for each task seem to be:

1. Clinical Urgency: how sick is the patient and how urgently do they need intervention? This variable, fortunately, comes into play only a few times in the course of a given shift, even in a busy ED, and, of course will propel the affected item to the top of the to-do list.
2. Benefit/Importance: How much will accomplishing this task move this project forward? Conversely, what are the consequences if I do not get this item done immediately? This has more to do with how long they have been waiting, how pissed off they are, and how much not doing the task will delay disposition
3. Time consumed: How long will this take to get done?

This will let me rank the order in which I intend to do my tasks. Of course, the value of a given task will change with time – patients’ clinical conditions evolve, the low-benefit stull become more important the longer the patient waits (e.g. putting in a couple of stitches may be the least important thing you need to do for the trauma patient, but you can never discharge them till it’s done, and as all the other tasks are completed on that patient, the stitches become the only thing keeping them there), etc. I generally am ready to pick up a new patient when all my to-dos are U(L)B(L)T(Q) or better. The worst thing is when I get pulled out of the work cycle for a long time (doing a procedure or tending to someone really sick) and everything is at the same rank because it’s been neglected for so long.

It’s really amazing, when you think about it, that we all do this more or less unconsciously, without a lot of formal thought. Some are better than others – I’ve seen a lot of folks who are very slow and carry a small patient load because they couldn’t effectively organize their workload. I like to think I am pretty good at it.

Of course, this whole discussion neglects the external interruptions which plague every ED doc through the day. One study suggested that the average ED doc gets interrupted 20 times ah hour.

05 January 2006

What on earth was USC thinking of going for it on 4th and 2 with the lead? I have never seen a coach so obviously lose the game for his team with a single bad decision.

Young is amazing, but IMHO the MVP has to be given to his offensive line. He was never sacked, had tons of time to throw, and every time Young scrambled, the line had the key bl0ck to spring him into the flat. AND, with literally dozens of running plays that took a ton of time to develop, there was not a single holding call against Texas.

Young will be the #1 draft pick.

Did anybody else notice that all the BCS games this year were spectacular? I can't remember a more exciting championship game ever (though I'm not a huge NCAA fan, so my knowledge base is limited), and the Penn State game was great, the Ohio State game was great, and the WVa game was great. What a great Bowl season. Now all I need for a perfect football winter if for the Bears to meet the Seahawks in Seattle in the NFC championship (if so, rest assured, I will be in the stands).

02 January 2006

Early on Aug. 3, 2005, we heard that 14 Marines had been killed in Haditha, Iraq. Our son, Lance Cpl. Edward "Augie" Schroeder II, was stationed there. At 10:45 a.m. two Marines showed up at our door. After collecting himself for what was clearly painful duty, the lieutenant colonel said, "Your son is a true American hero." [ . . . ]

Though it hurts, I believe that his death -- and that of the other Americans who have died in Iraq -- was a waste. They were wasted in a belief that democracy would grow simply by removing a dictator -- a careless misunderstanding of what democracy requires. They were wasted by not sending enough troops to do the job needed in the resulting occupation -- a careless disregard for professional military counsel. [ . . . ]

This is very painful to acknowledge, and I have to live with it. So does President Bush.

It's New Year's Day, 2 AM, and I am hunched over the fact of young male, inhaling the pungent aroma of dried blood, saliva, and alcohol, trying not to listen to his foul-mouthed drunken ranting as I try to piece together the tattered remnants of his face with a needle and thread. He claims to have "no idea" why some "two dudes" would have done this to him, but the longer I am having to spend in intimate proximity with this charming gentleman, the more I am kind of wishing I had had a chance to grind his face into the asphalt, too.

Finished, I step back and admire my work. Not too bad -- it will scar, of course, but not disfiguringly so. He calls me a 'bitch' and demands his shoes back. They are in the nursing station as a ploy to keep him here till he sobers up. Shortly after I leave the room, another patient's family member informs us that he is gone, last seen heading out the emergency exit and south on Nassau street. Security gamely goes after him but fails to find him.

An ambulance has just brought in my next customer now: he has been drinking and "fell down." He has a large laceration on his chin which the nurse says will need stitches. I can hear the medic phone ringing off the hook. Deep breath, straighten the shoulders, and once more into the breach.

Shadowfax

About me: I am an ER physician and administrator living in the Pacific Northwest. I live with my wife and four kids. Various other interests include Shorin-ryu karate, general aviation, Irish music, Apple computers, and progressive politics. My kids do their best to ensure that I have little time to pursue these hobbies.

Disclaimer

This blog is for general discussion, education, entertainment and amusement. Nothing written here constitutes medical advice nor are any hypothetical cases discussed intended to be construed as medical advice. Please do not contact me with specific medical questions or concerns. All clinical cases on this blog are presented for educational or general interest purposes and every attempt has been made to ensure that patient confidentiality and HIPAA are respected. All cases are fictionalized, either in part or in whole, depending on how much I needed to embellish to make it a good story to protect patient privacy.

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